A nurse is caring for a mother who delivered vaginally 2 hours ago.Select the 4 findings the nurse should report to the provider.
Fundus midline and firm at the umbilicus.
Moderate lochia rubra with no clots.
Constant trickle of blood at the vagina.
Hemoglobin level.
Heart rate.
Correct Answer : C,D,E
Choice A rationale
A fundus midline and firm at the umbilicus is a normal postpartum finding and does not require reporting. It indicates that the uterus is contracting as expected to prevent postpartum hemorrhage.
Choice B rationale
Moderate lochia rubra without clots is expected in the immediate postpartum period and does not need to be reported. It is part of normal postpartum bleeding as the uterus sheds its lining.
Choice C rationale
A constant trickle of blood at the vagina postpartum could indicate a laceration or retained placental fragments and should be reported to the provider for further evaluation and management.
Choice D rationale
Hemoglobin levels can provide important information about the mother's blood loss during delivery. A low hemoglobin level could indicate significant blood loss and necessitates reporting.
Choice E rationale
An abnormal heart rate in a postpartum mother could be indicative of complications such as hemorrhage or infection and should be reported to the provider for further assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While burping is important after feeding to prevent discomfort and regurgitation, it does not directly indicate overall health or hydration status.
Choice B rationale
Frequent loose yellow stools are typical in breastfed infants and indicate proper digestion and nutrition, but do not address overall hydration status directly.
Choice C rationale
Steady weight gain indicates good nutrition and overall health in the infant, reflecting adequate feeding and hydration.
Choice D rationale
Sleeping through the night is not an expectation for newborns, as they typically need frequent feeding due to small stomach capacity and rapid growth needs.
Correct Answer is C
Explanation
Choice A rationale
The Moro reflex is a startle response in newborns and does not assist in promoting latching during breastfeeding.
Choice B rationale
The stepping reflex, also known as the walking reflex, involves a newborn making stepping movements when held upright and does not contribute to latching during breastfeeding.
Choice C rationale
The rooting reflex causes a newborn to turn their head toward a touch on their cheek and begin sucking movements, which is crucial for promoting latching during breastfeeding.
Choice D rationale
The Babinski reflex involves the toes fanning out when the sole of the foot is stroked and is unrelated to latching during breastfeeding. .
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